ESC: Concomitant LAA Closure During Heart Surgery Scores a Win

But will making it routine safely prevent strokes?

BARCELONA -- Preemptive closure of the left atrial appendage (LAA) during heart surgery had long-term protective effects on the brain in a single-center study called LAACS reported here.

When patients at high risk of atrial fibrillation (Afib) and stroke were randomized to LAA occlusion during first-time heart surgery, rates of combined clinical stroke/transient ischemic attack (TIA) and silent cerebral infarct were reduced over a mean of 3.7 years: 5.0% versus 16.3% for leaving LAA open (P=0.02), said Jesper Park-Hansen, MD, of Denmark's Bispebjerg-Frederiksberg University Hospital at the European Society of Cardiology meeting.

Clinical strokes and TIAs occurred in 3.0% and 9.3% of the closed-LAA and open-LAA groups, respectively, though the difference failed to reach statistical significance (P=0.07).

Per-protocol analyses yielded similar results.

Nine of the 14 cerebral ischemic events in the control arm occurred 1 year after procedure.

"This is the first randomized study of surgical LAA closure indicating a long term protective effect," Park-Hansen told the audience, concluding that "most patients undergoing open-heart surgery may benefit from LAA closure surgery."

But Volkmar Falk, MD, of the German Heart Institute Berlin, sounded a note of caution.

Serving as discussant at the late-breaking ESC trial session, Falk noted that Hansen's group randomized 187 out of the 205 patients enrolled -- and of the LAA closure group, only 10% had transesophageal echocardiography done to confirm completeness of the procedure.

Falk was also skeptical that endocardial suturing can be trusted to occlude the LAA, citing a study finding that this technique leaves more than half of the LAA still remaining. "This is not the best method," he said.

LAACS included patients with a mean CHADS-VASc score of 2.9 whether they had a previous diagnosis of Afib or not. Surgeons in Park-Hansen's group developed a surgical LAA closure protocol using double closure with purse-string closure and single running suture ligation.

Baseline Afib status, CHA2DS2 -VASc score, or use of oral anticoagulation did not affect the protective effect of LAA closure seen in the study.

LAA closure was not associated with particular adverse events. That said, both open- and closed-LAA groups had fairly large rates of perioperative Afib: 60.5% and 50%, respectively, which did not differ significantly.

Falk suggested it would have been helpful to have information on how acute Afib was treated.

His take-away: "This may add to the confusion, but LAACS will not affect guidelines. LAACS is an important piece of the puzzle, but the picture is not yet complete."

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